The irony and the agony of our prescription opioid problem

It’s almost unthinkable that in an era preoccupied with “evidence-based” medicine and “best practice” advice, one of the worst drug problems in the United States flows right out of our health care system. Unlike other major epidemics such as those connected to methamphetamine, crack cocaine or other illegal drugs, our prescription opioid problem is full of irony and agony, because it has been fueled, to a certain extent, by the actions of well-intended medical doctors. Physician-prescribed opioid medication misuse is multifactorial in its origins and has proved an equally complex puzzle for those who are working to find a solution.

But we do need to find a solution. But where did this problem begin?

As recently as the early 90s, a patient would have to present with cancer or a painful, terminal illness before physicians would write a prescription for ongoing opioid pain medication. Although these drugs were commonly used for short term, acute pain connected to a procedure, surgery or injury, prescribing them long term was considered a bad idea. For example, in 1992, a physician survey found only 12% of physicians believed that giving patients opioids for chronic pain was a “lawful and generally acceptable medical practice.” In other words, almost 90% believed it was unacceptable. How that changed is a fascinating tragedy.

Ironically, this public health disaster begins with physicians wanting to help their patients, specifically their patients with chronic pain, which millions of Americans live with on a daily basis. The reason that physicians had always been reluctant to use powerful opiates to treat these kinds of chronic pain- arthritis, bad knees and backs, was because the risk-benefit analysis involved in putting somebody on long-term opioids was considered a losing proposition. Doctors knew that their patients would become physically dependent on a morphine-based drug, with all of the well-known side effects (sedation, constipation, sexual dysfunction, etc) and that they would need larger doses over time as tolerance to the drug developed. They knew that after a not-very-long period of time, if their patients wanted to go off the medications, they would suffer the misery of opioid withdrawal. So it just didn’t add up- better to cope with the pain without using morphine derivatives than to start one’s patient down a predictable road of addiction.

The equation started to shift about a decade ago, when a movement to more adequately treat patients for pain gained momentum in the medical establishment. Doctors became more concerned about adequate pain management as a cornerstone of good practice and were broadly encouraged to take their patients’ reports of pain more seriously. They were told to stop viewing pain as an inevitable symptom of primary illness or aging but instead to look at pain as a primary issue in its own right that deserved the most robust treatment possible. As Dr. Anna Lembke noted in a recent article published in the prestigious New England Journal of Medicine, ”in contemporary medical culture, self-reports of pain are above question, and the treatment of pain is held up as the holy grail of compassionate medical care.”

At the same time, Dr. Lembke points out, a paradigm shift was also happening in the larger culture. On a global level, it has become more and more of an accepted notion that there is a pill for any ailment or discomfort, and that all less-than-optimal situations, difficulties or disturbances can and should be alleviated pharmacologically. So the pain pill epidemic should also be viewed in context, in this case a nation where over 20% of American women are on an antidepressant and many millions of men, women and children can’t live without their daily Xanax, Ambien, Adderall or other forms of pharmaceutical life-support.

So now the patient, now viewed by some as “the health care consumer,” is bombarded by television commercials for an array of pills that can fix any problem—shyness, sleeplessness, fibromyalgia or pain. Patients who walk into their physician’s office now arrive with a culturally validated expectation of relief. To add to the dilemma, doctors who refuse to deliver the goods, even if they are doing so in the best interest of their patient, know that their average patient rating on Yelp.com, and perhaps ultimately their practice, may take a hit, since these ratings frequently include questions about how well the doctor responded to the patient’s reported pain. As Dr. Lembke notes, “health care providers have become de facto hostages of these patients, yet the ultimate victims are the patients themselves.”

Unfortunately, along with the additional training and focus on pain management, there was no commensurate attention given to helping physicians understand, screen for, and treat addiction. Had there been a push to manage pain along with a corresponding effort to help doctors understand the nuances, complexities and dangers of addiction, we would likely be looking at a very different landscape.

How did it happen? Ask Big Pharma

The other necessary element in the pain medication debacle is the development and marketing of opioids and opioid research by drug manufacturers that were unbelievably well-received by not only physicians but also the Food and Drug Administration. As described in a recent Washington Postarticle, drug manufacturers, particularly Purdue Pharma, the maker of Oxycontin, and the researchers that they hired, put out a variety of scholarly articles that seemed to alleviate many of the concerns that the medical profession had long accepted as common knowledge.

Their research, which was published in the most prestigious, peer reviewed journals, including the New England Journal of Medicine, indicated that there were “inconsequential” risks of addiction, dependence or withdrawal symptoms from the long term use of opioids with true pain. The FDA-approved labeling for Oxycontin included the following language: “The development of addiction to opioid analgesics in properly managed patients with pain has been reported to be rare” (the language was removed from the label in 2008). Physicians were told that patients with legitimate pain wouldn’t experience, and crave, the euphoria that opiates can generate, because the pain interferes with the euphoric response to the drug.

The take home message that was inculcated into the physician community was essentially that people in legitimate pain, under the proper care of a physician, will not develop the same kind of addiction problems that other people taking the same drugs inevitably would. Illogical as it sounds, and untrue as we now know it turns out to be for millions of patients, the message took hold, and the mantra of the profession shifted. Now, the thinking went, if these medications, properly prescribed, to the right kind of patient, will not cause the kinds of problems we thought they would, why would a physician fail to adequately care for patients’ pain? This shift in focus has inadvertently caused a tremendous amount of misery. And, despite all we now know, the battle for turf in the opioid market goes on, with new, and stronger opiates vying for market share and generic formulations of Oxycontin on their way.

Additionally, there are important problems in the supply chain that is responsible for safely distributing these powerful medications, with numerous opportunities along the way for drugs to be inappropriately diverted. At the same time,the Drug Enforcement Administration is petitioning the FDA to categorize Vicodin as a Schedule II drug, which would impose significant new barriers to patients.

How bad is it?

Now that we have a basic understanding of how this problem arose- how bad is the problem? Extremely bad. First of all, we had a huge drug problem before the pain medication crisis: “Addiction is the largest preventable health problem in the United States- affecting 16 percent of the population- more than heart disease, cancer or diabetes”, says Susan Foster, CASAColumbia’s Vice President and Director of Policy Research. And then, into that addiction continuum, where many misuse multiple substances, add prescribed opioids, which are particularly troubling because the risk to each user is enormous:

Vicodin and Oxycontin are the two most misused prescription drugs in the country.

More people are addicted to prescribed opioids (somewhere between 2 million and 2.4 million) than to heroin and cocaine combined, and prescription drug misuse “remains the fastest-growing drug problem in the United States,” according to the Centers for Disease Control and prevention.

More people die of drug overdoses than by any other cause of accidental death, with the majority, about 15 million people, dying each year from prescribed opioids. One reason for this is that as tolerance develops to the pain relieving effects of the opiate, users take higher and higher doses to achieve the same pain relief. But the users’ respiratory system doesn’t develop the same level of tolerance as the dosages get higher. Eventually, the user is on such a high dose that breathing can slow down to the point that it stops. This scenario is common in opiate dependence in part because the user may be sedated and confused, unable to monitor dosages properly and likely to make medication errors. For the first time since records have been kept, more people are dying of accidental drug overdose than in car accidents.

Opioid addiction, pound for pound, is the most dangerous addiction. Setting aside the sheer number of opiate-addicted citizens, the risk of death to any one user is higher than for any other drug. People who are addicted to opiates are almost 6x more likely to die than they would be if they were not addicted to opiates- making opiate addiction more dangerous than addiction to methamphetamine (#2) and other drugs and alcohol.

The number of infants born dependent on opioid painkillers and diagnosed opiate withdrawal upon delivery has tripled in the last decade, to 13,000 in 2009.

Certain regions of the country, Florida is famously one, parts of Appalachia another, are simply devastated by frightening rates of addiction to pain medications. In these regions, up to ten percent of infants are born addicted to opiates. In Florida, in 2009, death by overdose of prescription drugs was about four times that attributed to illegal drugs.

Where do we go from here?

Now that we have a pretty clear sense of the basic forces that have led to the problem, and the extent of it, two essential questions are raised. First, what should be done for the two million people who are addicted to prescribed opioids. Second: what can be done to prevent more people from finding themselves in the same situation. Where do we go from here? What needs to change? We’ll tackle those questions in Part II of this article, which will be coming soon.

The irony and the agony of our prescription opioid problem 37 comments

Mismanagement and over prescription of opioids is rampant and reckless. In order to bring in patients, many hospitals and MDs’ knowingly feed addictions. Many create addictions in post op patients. Furthermore, the over prescription leads to other morbidity s’ which can result in death, respiratory depression, malnutrition, debility, accidents, depression, etc. Death due to over-prescription is becoming all too common and acceptable. I have too often seen Hospice nurses deliver a lethal dose of morphine to a comfortable, sedated patient resulting in their premature death. Many times this is the intended purpose. I have seen relatives demand that the patient receive unnecessary doses of morphine, simply to expedite the patients demise. Abuse is common and tolerated at the expense of the patients health. Morphine does not directly kill pain. It depresses normal body function allowing a patient to remain in a static position of comfort for an extended period of time. They experience pain when they move or are touched; this is why muscle relaxants work well for certain types of pain. The opioids are, for all intent and purpose, for profit medication, simply put!

Suzi Q 38

I saw no reason to keep my MIL alive.
I didn’t know that the doctors gave her too much morphine and she died.
All I know is that she had been suffering greatly, minute by minute for months while her lung cancer “ate” at her. She cried out in pain many times for weeks and months and suffered enough.
I was o.k. that the doctors did that.

Suzi Q 38

As far as drugs like Norco and Vicodin, I am on Norco right now.
I had my anterior cervical spine discectomy two weeks ago.

When I first woke up from the surgery, my throat was “on fire.”

Eventually, I got back to my room and could give myself an infusion of I.V. painkillers, I think I pushed that button 4 times the first day.

By the time I got home, I took 1 tablet 3 times a day.
Within a week, I voluntarily decreased the dosage to
1/2 tablet twice a day, then 1 full tablet at bedtime.

Now that it has been two weeks, I don’t take anything in the morning.
I take 1 500mg Tylenol (no Norco) at 12:00 noon and then 1 full tablet a bedtime. I will continue this for the next week.

On Saturday, 2/9, I will take Tylenol at noon and then 1/2 a Norco at bedtime, just to see if this works. I still feel a little pain, but so what.

I am that concerned about becoming addicted and dependent to pain medication.

I also know that everyone’s condition and pain is different.

I think that doctors and nurses should tell the patient how to get off of the medication. A good time would be the two week visit post surgery. They should write down and give them a sample titration schedule that systematically decreases the dosage every few days or week.

buzzkillerjsmith

I had a ruptured disk in a my back a number of years ago. Very painful. My doc gave me 30 Vicodin and they helped the pain a lot. And after taking 4 per day for a week I was also so depressed I didn’t want to get our of bed. Quite an eye-opener for me, a doctor of 23 years. Now when the back acts up it’s ibuprofen and ice.
Different people are different, but opioids made me dysfunctional in less than a week.

Suzi Q 38

Yes, we haven’t even touched on the side effects.
Thank you for your post.

http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

SuziQ, wishing you a good recovery from the surgery you had and that you get to feeling better than you did before real soon.

Suzi Q 38

Thank you Kristy.
I hope that the surgery makes me stronger.

http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

Suzi Q, I hope so too. Having read your story and what you have been through already, and now this I am like, “may this help her”. I hope that the post-op pain is now easing up a bit more than it did yesterday. ((((Hugs)))

Suzi Q 38

Thanks, Kristy.
I Just woke up from a nice sleep, thanks to my Norco last night.
Since it was so good. I think that when I go to bed to night I will take only 1/2 Norco tonight.
During the day I will strictly take only Tylenol.
I would love to take Advil, but the surgeon told me no.
I wonder why? I will be seeing him on Wednesday for my check up.

Suzi Q 38

Yes, my post op pain is easing up.
Thanks.

buzzkillerjsmith

We just had a new doc join our group. She basically inherited an Oxycodone patient panel in Virginia where she used to work. She tried helping to get pts off this stuff, but they wouldn’t go for it. She was threatened from time to time. Man was she glad to get out of there.

Fortunately we have a pain clinic in our area. Pretty good, pretty stingy with the opioids. Pts don’t know. They’re hurting and want relief and opioids provide relief–and then tolerance, and then depression, and then dysfunction. They should be the absolute last resort in treating chronic non-malignant pain.

Suzi Q 38

I believe it.
I was in a pharmacy in Los Angeles and the patient was crying uncontrollably, which eventually graduated to shouting at the pharmacist to give her her pain meds. She demanded that he call her doctor’s office right then and there. Of course the doctor said “no way,” and she just couldn’t understand what “no” meant.
I thought that she was going to climb over the counter and get the drug herself.

Another story involved a pharmacy and pharmacists that had to deal with addicts that came into their pharmacy with guns demanding
drugs. Unfortunately, the punks killed everyone in the small pharmacy that day. Two pharmacists, one clerk, and one customer.
I used to visit that pharmacy every couple of months. The word came out that it was for the drugs, not necessarily for the money.

Once they are addicted, it is hard to get them into a program because they feel so good while on the drugs.
I will have to say that my pain is better managed, and I can sleep at night with it.
It definitely can be dangerous if you have given too much to a patient and have to sy no someday.

What is sad is that they will just go to another doctor, all too happy to write them a prescription.

ninguem

Suzi Q – Is there a way to keep track of what these patients get?

Some states keep a database. Some don’t.

It’s usually called a PMP or PDMP, prescription monitoring program, or prescription drug monitoring program. The natural concern is privacy. Make sure access is limited to healthcare practitioners with a reason to query the database, make sure the person querying is looking for his/her legitimate patients, not looking for fodder for gossip. And make sure it’s not being used for law enforcement to go on fishing expeditions.

Suzi Q 38

I am not sure the state of California has this database.
Step MIL obviously had a problem with these meds.
I would see the bottles of drugs on the kitchen counter.
When she depleted his savings account, there was an audit of both of their incomes and expenses.
I noticed the pharmacy one right away, so we asked her. Fil had had 3 strokes, so he couldn’t respond.
She said it was HIS meds.
I found that hard to believe, since he was on an antibiotic and an aspirin. Also most other medically necessary drugs were covered by his medicare.

I decided to ask the lawyer to subpoena the list of drugs they both were on. The lawyer refused, telling me that no judge would allow us to invade her privacy like that.

I insisted that they at least subpoena HIS drugs, thereby showing that the costs were mostly hers. If so, I suspected opiates and therefore she would not be the best candidate to make medical decisions for my FIL.

The lawyers still refused, until I told them that they had to do it.

They did, and the judge approved the subpoena.
The pharmacist received the court documents and made the error of sending BOTH lists of drugs.

It showed which doctors requested the drugs.

Six different doctors….wow, she had a huge problem.

Anyway, she wanted her opiates so much that she ended up settling early and giving us conservatorship of her husband of 5 years. She said she simply didn’t want her family or other physicians to know what she did.

We explained to her, that knowing what we knew about her, that she was not capable of caring for him with all his medical problems.

She reluctantly signed the papers to avoid a costly trial.

Jen S

I’ve had a few surgeries since 1999. Each time I was alarmed at just how much pain killers I was prescribed. Most recently I underwent a lumbar discectomy in 2011 and a liver resection in 2012.

For the discectomy, I was prescribed 100 Oxyvodone and about the same in a muscle relaxer that is catergorized as a controlled substance. Being apprehensive about such meds, I took the oxy for about 4-5 days. A few times at night once PT started. I have over 60 pills left…

Ironically, the first thing the spine surgeons office says when I call is if I need a prescription…and that is at Hospital for Special Surgery..

After the open liver resection at MSK I was given hydromorphone – 60 tabs, 4mg. Once I came home and looked up the drug, I was shocked to say the least and realized three was no way I was going to take it. So, I took it morning and night for a 2 days then just at night for a few days.

Surgeons want to ensure their patients are as comfortable as possible and each patient has a different pain threshold. Yet, I can’t help but wonder of both HSS and MSKCC are so generous because then it will direct patients to their Pain Management division…

On the flip side there are no measures in place in pharmacology or medicine.. There really needs to be system where if a patient goes to one pharmacy and fills oxy that pharmacies elsewhere will have a record of that.

Also, such drugs should be dispensed in smaller quantities. This would result in more doctor visits (which hopefully would result in the doctor identifying tell-tale signs of addiction).

I’m a child of an addict (substance and Rx) and I have spent most of my life volunteering with urban kids of the same here and abroad. Having seen the ravishes of addictions and the long-term impact first hand makes me apprehensive with taking anything.

So, although I have 13 herniated discs and am in constant pain, I chose to do what I can in disconnecting from it, take mild meds, PT, etc. This is my choice as EVERY time I walk into a doctors office (PCP, Physiatry, Surgeon, etc) they always question why i choose not to take x, y, or z? Not to mention I have tried many of the drugs without enough relief to justify (for me) taking them. None of the doctors respect my decision to avoid all controlled substances (including Lyrica) and patronizingly say “if the pain is really as bad…”

The problem is multilevel but there certainly is something more doctors and pharmacies can do to curb it.

Suzi Q 38

Wow. you have been through a lot.
It is good that you have been able to wean yourself off of the drugs so quickly and systematically.
Some doctors don’t want to curb it, as It keeps the patients coming, I imagine. Thank goodness most doctors are good. Unfortunately, there are always those that don’t care as much about the patient as their own practice as a business flush with patients.
Ditto for certain pharmacies. The more they order, the more they sell.
My MIL was spending $600.00 a month or more cash for her pain meds.

Laura Dunn

In response to where it started, I’d have to say JHACO. Does anyone recall the campaign “Pain as a vital sign?” In an inpatient setting anyway, that’s where I saw the major increase and eventually pain clinics were appearing everywhere. I puts the provider in a damned if you do, damned if you don’t position.

Suzi Q 38

Yes, there is a fine line. What does JHACO stand for?
No, I don’t recall the campaign, but what a good slogan (“Pain as a vital sign.”)
I would think that the common fever is a sign to medical that something is wrong. The same could be said for chronic pain.
I was discouraged from attempting to find out what the source of my pain and neuropathies were.
The neuro would just encourage me to take Tylenol, Advil, Neurontin and Lyrica.
After about 2 months of taking one or the other (Neurontin, then Lyrica) and experiencing a huge weight gain and other side effects, I finally asked the neuro: “Why do I have the neuropathies and pain at all?”
I will admit my BIL’s pancreatic cancer and sad outcome played a part here.
The doctor did not have any interest in finding out why.
I know now that that is the time to find a new doctor that is a bit more interested in my care.

cbuckleyrn

When this started I remember asking a patient in triage to rate her pain on a scale of 0-10 (she had a subungual hematoma sustained the day before), she answered 9. I asked her did she have kids… yes…NVD… yes…. so if pushing the baby out is a 10 what is her finger pain? Still replied 9. Went by the Baker Wong Scale after that.

Kobukvolbane

Throw those 60 pills out! (And just FYI, Lyrica is not a controlled substance.)

Jen S

Lyrica is a Schedule V controlled substance under Title 21 of the Code of Federal Regulations.

Kobukvolbane

You are correct. My bad.

NormRx

Duncan, I thought the same thing when I read the blog. I hope the author responds, I think he means 15,000.

Duncan Cross

Yes, a response would be great. It’s not just that he’s wrong about the 15 million/thousand — it’s that he implies prescription opioid abuse is a bigger problem than traffic fatalities. Then in the next paragraph, he implies that rx opioid addictions are particularly deadly, using a source that includes heroin deaths in opioid addictions, from a study of people who have *already* been hospitalized for drug abuse. He also ignores the 25,000+ people who die each year from alcohol-related causes (not including accidents and homicides!). It looks for all the world like he is trying to inflate the harms of these medicines, while minimizing their benefit.

http://www.facebook.com/shirie.leng Shirie Leng

NO, NO, NO, NO! The problem with opioid addiction is the ADDICTION part. Millions of patients are prescribed a short course of opioids for post-operative pain and never become addicted to them. People should be held responsible for what they put in their mouths. This is not the doctor’s fault.

StoweLocke

It is ironic that the author mentions “evidence-based medicine” and “best practices”, because the article advances neither. The above history completely misses the mark on what has been learned about pain treatment made in the past decade, specifically in terms of our understanding of pain itself, and the relationship between central sensitization and chronic pain. As a bioethicist who has lived with severe chronic pain for the past 22 years, I am bewildered at the ignorance expressed, both in the article and in the comments.

A few factual errors have been stated which I would like to correct. First, opioids, when properly supervised, have never been linked to premature death. Second, addiction is quite distinct from physiological dependence.

Buzzkillerjsmith, you clearly do not understand pain management, and I sincerely hope you tell your patients exactly that.

SuziQ38, extrapolating evidence from anecdotes is, at best an example of a representative heuristic, and at worst confirmation bias.

The two of you, and the author, are continuing to perpetuate the poor reasoning and unfounded belief system that many of us hoped had been shed back in 1998 when failure to properly medicate a patient resulted in a reckless negligence conviction in California (Wm. Bergman). Pain became the 5th vital sign during the 1990’s, first by the APA, and later by the Dept. of Veteran’s Services; it is now taken as a given. Doctors who fail to recognize this are dinosaurs, and have no business treating patients in pain., either practically or ethically.

At the core of this is people who have no idea whatsoever what chronic pain is like, let alone severe chronic pain. No conception. I am quite certain the author falls into this category, as do the aforementioned commentators. Put a face on the people you dehumanize, and yield to a less cavalier attitude towards those whose lifelong condition you cannot fathom.

Suzi Q 38

“SuziQ38, extrapolating evidence from anecdotes is, at best an example of a representative heuristic, and at worst confirmation bias.”

This is not new news. My posts are full of personal bias. It is my world.
So far, I have not had to abuse my Norco or Vicodin.
I think, after my routine hysterectomy, the doctor prescribed 60 Vicodin. I probably used about 10 or 12.
Within 4 months, I needed to go back into the OR with the same gyn/oncologist for a minor surgery to cauterize an area. That was day surgery and I was released within 3-4 hours. He gave me another 30 Vicodin. i probably used 6.

For this surgery (on 1/18) anterior discectomy, I was given only 30 Norco. I am going to probably need 25-30, so the doctor is “right on.”
Also, I can always call the office for more if I can plead my case well enough.
More anecdotal information, but real just the same.

I have a lot of time to contemplate how I am going to attempt to wean myself from the pain meds. I am trying not to savor the feeling that taking the meds at night does for me. I am proud that I can do without them during the day, and just take the Tylenol.

I realize that not all patients can do that.
But I agree with Dr. Leng. There are those of us that use it for short term and don’t become addicted if we work at it.

I didn’t appreciate the Neurontin, Lyrica, and Vicodin before finding out what the source of my problems were.
Once the source is discovered, the diagnosis is made, the treatment is fairly successful, I agree that the painkillers, if used sparingly and responsibly, have a place to treat me or anyone else with chronic, severe, pain.

It is just that these drugs tend to mask a lot of complex conditions that want to emerge and beg to be treated by the professionals that many of you are.

If only you could take the time to uncover the real problem(s).

StoweLocke

I’m sorry, I thought that a problem that affects more people than diabetes, heart disease, and cancer combined was a real problem. Quoting Time magazine:

“Making matters worse is the media and political attention that has been devoted to painkiller abuse and addiction. Conversely, very little attention is given to chronic pain, which affects a far greater number of people.”

Chronic pain costs over half a trillion dollars annually, which certainly has more to do with the current ‘problem’ than Big Pharma, yet the author poses the abuse issue as if it should be out primary concern. This fear mongering seems to be working.

For example, you seem to be concerned about addiction, but there is very little chance of that happening if you take meds as prescribed. A recent study determined that only 1.8% of chronic pain patients experienced an overdose of any kind (Annals of Internal Medicine, American College of Physicians, 2010), although there can certainly be abuse below overdose thresholds.

The argument to withhold treatment is simply counterproductive. Pain Research and Treatment studied opioid abuse, reporting, “Those who are undermedicated may demonstrate drug-seeking behaviors or try and self-manage unauthorized dosage increases in an attempt to find relief. Among many of these patients, once adequate relief from the pain is obtained, the drug-seeking behaviors, otherwise known as pseudoaddiction, disappear.” (D. E. Weissman and J. D. Haddox, “Opioid pseudoaddiction: an iatrogenic syndrome,” Pain, vol. 36, no. 3, pp. 363–366, 1989.)

There is, no doubt, a prescription drug abuse problem. However, its not nearly as big a problem as the preventable suffering of nearly 1/3 of the country.

Suzi Q 38

I am certainly glad that if I take the opiate drugs as prescribed that there is little chance for addiction on my part. I will take comfort in that.

I refuse to allow one article to dissuade the realization that there are so many others that are walking, working, and have become addicts prematurely or needlessly. There should be an easy way to check to see if any particular patient is getting these types of drugs from other doctors. There is room for physician complacency and patient abuse.

The article that you cite is in reference to one 17 year old patient with leukemia, pneumonia and chest wall pain. Since it is just one example, and I allowed to describe this as “anecdotal?”

In this case, he had a lot more going on than I do.
His pain is not my pain, just as my MIL’s pain from lung cancer was very different than mine. She got morphine, which I found totally understandable. The iatrogenic syndrome may be harmful here as the patient is feeling a lot of pain. At any rate, I could not read the article in its entirety because I don’t subscribe to that site.
Who gets to measure the pain? What were they comparing, patients that received the drug immediately after asking no matter what vs. doctors that witheld drugs for awhile? If so, for how long?

Who determines who gets what or how much, for how long? You do, based on your experience and what your patient’s diagnosis is and what he or she says his level pain is.

In the end it is the doctor’s decision, based on medical knowledge and judgement.

How about a patient like myself, who tolerated the surgery as far as pain fairly well, and doesn’t need it?
Do I just take it as prescribed without truly needing it?
What if low doses of Tylenol does well enough during the day? What if I prefer it this way. Can you concede that I am different from some of the others and can tolerate pain fairly well? What if I decide that it makes me feel really, really good, and I like this feeling all the time?
Do I get 2 or 3 more refills without questions?

What if I call your office 2 months from now, and ask for 2 mor 3 more refills? You know that I shouldn’t need that much, but don’t want to be the cause of my iatrogenic addiction. God forbid you say “no.’

I just think that yes, in severe cases the prescription of these drugs are warranted. Yet, in cases like mine they are not, and given the chance can lead to addiction and abuse. Not to mention that prescribing such for prolonged periods without determining the true cause of the pain can itself cause a iatrogenic syndrome.

It is interesting that Dr. Leng has found information that shows that there is not that much addiction.
That is good to know.

Sarah

Thank you for writing what I believe. Well done!!

Susan Czarnecki

Thank you for responding so well to this article ! This author is CEO of a business firm whose role is coaching businesses in more efficient practices. The wolf in sheep’s clothing.

I am sitting here terrified of how I am going to handle my future ! I have a slow growing, but complicated malignant tumor and some weird severe neuropathy issues. My team is a Palliative Care team who closely monitor my care. I am very conservative in using pain medication and accept coping with a moderate level of pain. The changing attitudes in this new world of medicine make clear if I was socially conscious I would go out to sit on the mountain top and let nature follow its course. I had my turn in the world and I should leave the minimal resources left for younger members who still contribute. It is not about care any longer, more like living “survival of only the fit.”

Suzi Q 38

Thanks Norm, good information.
Obviously there are doctors out there prescribing these drugs when it is not clearly needed.
I remember a neighbor came over and asked me if I would consider selling my extra.
I told her “no,” as I didn’t want to go to jail.

Suzi Q 38

“They were going to call it South Lake Union Transit, then they realized people would ride the SLUT.”

Thanks for the information about the JCAHO.
What is the big deal about the Joint Commission???

Very funny about the acronym for South Lake.

http://www.facebook.com/jlschuster1 Janice Lynch Schuster

Aside from the nuances presented in the comments below, I would just like to add my voice, as the relative of someone who moved from a prescription-drug addiction to a heroin-addiction. For many years, I have written about end of life care and pain management, and was part of the crowd rallying for better and more prescribing. Surely, we can ease the pain associated with dying from cancer! At the same time, I was lulled by the now-apparently misleading research put out in the late 1990s and early 2000s, that the consequences of opioid use would somehow be “inconsequentia.” They have not been inconsequential to my family, in which we have come close to death of the addicted relative. Those consequences have been severe. We struggle with them daily.

http://profiles.google.com/edwardpullen Edward Pullen

For me the most interesting thing on KevinMD is that the two articles with huge reader commentary are this one and the article on gun violence. These are two major societal problems, and ones that evoke emotional commentary. I too have found that the articles most enthusiastically commented upon are about pain medication issues.

meyati

I can’t even get anything for short term pain. I had part of my nose and mouth removed because of cancer. I was sent home without anything. I used sherbet for relief- Do you think that I wanted to sit 6 hours or more in an ER to try to get pain relief? I tripped while jogging, and jammed my arm into the rotator cuff-they thought it was broken. Do you think that they gave me anything? I live in the state with the strictest laws-I hate the DEA. They wanted to do radical surgery for the cancer-I told them that I’m not letting a scalpel near my face again. For any of you that think I have an anger problem- you’re darn right. Doctors today are cowards-Doesn’t help that I’m allergic to tylenol-so they say I’m a drug addict.

Sarah

Stowelocke Stated what millions know to be theTRUTH in pain treatment. Your post should be in every newspaper in the country!